Masks

The R&R and its Lubumbashi shopping spree for my Congolese friends at the hospital has come and gone already. Yet the fatigue stays – we have been tackling so many epidemics lately, and the measles is now a thorn on my side, as some of you know.

Vaccination campaigns in the Congo are traditionally supported by the big NGO’s and UN offices. The vaccines are donated by UNICEF and significant sums are provided to the Ministry of Health to carry out the campaign. Unfortunately, most campaigns in DRC see their funds deviated towards a few, deep, pockets. Children in rural, less accessible areas miss all the routine immunizations. Here in Shamwana, the coverage has been at best episodic for the last decade. Hence the epicentres of measles shaking up here and there. But the Ministry of Health is often reluctant to start emergency vaccinations because it would implicitly suggest that its previous, well-funded campaigns, were not effective.

When the first cases of measles happened a month ago, we started vaccinating in the affected villages, according to our MSF protocols, using the Ministry’s vaccines. In the context of an epidemic, MSF widens the age of immunization up to 15 years whereas the routine government vaccination is only until 18 months old. We made the mistake to inform our Lubumbashi office about our extended coverage right away. Because they were trying to get provincial Ministry of Health approval for our extended emergency campaign, everything had to come to a halt to show the goodwill of MSF to cooperate with the Ministry. We were told to stop all vaccinations at once. The negotiations on our side, in the field, with the local Médecins Chefs de Zone, were successful – it helped that both came by motorbike and saw the extent of the measles epidemic, with the extra tents and set-up already overwhelmed. But at the higher capital level, where the MSF Lubumbashi people were also lobbying, the approval for the emergency coverage was not obtained. Instead, we were instructed by the Médecin d’Inspection Provinciale not to do an emergency extended campaign, because the International Rescue Committee was to support another provincial Campagne de Rattrapage in January, with the associated funds. With, I mumble, the expectation to be as ineffective as the last one. So even if we have the approval of our local Bureau Central de Zone, they were forced to bend to the capricious decision of the provincial authorities.

Simply put, 4600 doses of unused vaccines from the previous mass routine campaign held in August are now sitting in our fridge in Shamwana and waiting for their expiry date. In the meantime, we have had 164 cases of measles in six different villages, and new cases keep on coming on a daily basis. To say the least, out here in the field, we are... rabid. Had we not informed the MSF capital office so swiftly initially, and simply gone through our regular channels through the Bureau Central, there might have been a window whereby we could still have gone forward with the extended vaccination. Because the local MoH was in agreement with us; and with the Congolese context of delays in communication and habits of long political discussions, the provincial level might have been informed much later, thus giving us a window of opportunity. Our Bureau Central people now think that the carpet was pulled from under their feet because of the prompt intrusion of the provincial authorities inadvertently facilitated by our Lubumbashi MSF office. Moreover, to vaccinate the measles-affected villages is feasible here with the current logistical equipment. The provincial Ministry of Health in Lubumbashi is de facto taking the children hostages by refusing to authorize our emergency vaccination, which does not cost anything. All this because it does not bring any supplementary funds to his office – I mean pockets, of course... We have to watch helplessly the measles spread and use up material and human resources, all the while knowing that the epidemic was altogether avoidable. The principle of international aid can be a pretty mask hiding an ugly reality when there is not much follow-up in the field. One must take into account the corrupted, tribal, ego-driven political infrastructures that are rampant on this continent. Ah, the arcaneness of dealing with Congolese officials and African realities! The road to hell is certainly paved with good intentions...

I now know next time to play dumb and to take advantage of the slowness of bicycle-driven messages used by the Ministry of Health to communicate with its hierarchy. We are all having fantasies of hiding in the night to go secretly vaccinate all these villages against measles. Historically, MSF had been known to defy Ministry of Health decisions or inertia, but there have been consequences. MoH’s have been known to denounce MSF on public radio, or even, we have been kicked out of some countries. With more experience and chaos in the humanitarian world, we are aiming for a better collaboration with the local medical authorities, but it can be a delicate issue that is difficult to take on.



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Parading on AIDS day in Shamwana on December 1st...


My absolutely fantastic medical team




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Sur ce, j’aimerais quand même tous vous souhaiter une bonne saison des Fêtes et une bonne année 2008! Que la joie et la paix soient dans votre coeur et que le nouvel an vous amène tous les souhaits auxquels vous aspirez!

Best wishes of health, warmth, luck, happiness and love for the holiday season! May 2008 bring you joy and fulfillment!

Epi

Arrivée

Il aura fallu trois mois pour que je m’extirpe de ma bulle de voyageuse et que je me pose vraiment ici, à Shamwana. Le sentiment d’être ici, de me sentir chez moi, que ça devienne mon familier, vient d’atterrir doucement. Je reconnais chaque membre du staff national à sa démarche, son timbre de voix, voire même son ombre. Distinguer un Congolais la nuit n’est pas tâche facile - pourtant maintenant je reconnais chacun d’entre eux quelle que soit la pénombre. Lorsque je suis partie en réunion médicale à Dubié la semaine dernière pour discuter avec les collègues de l’avancement de nos projets respectifs, je me suis sentie en terrain complètement étranger. Shamwana, c’est vraiment mon quotidien maintenant. Je me suis attachée à ce petit morceau de terre africaine comme je n’y aurais pas cru. C’est difficile à admettre pour quelqu’un qui a activement cultivé le nomadisme pendant les quatre dernières années. Mais ça fait tout chaud au coeur, tout simplement, finalement.

Nyombo, notre patient le plus malade de l’épidémie de choléra de Kishale, maintenant admis chez nous pour malnutrition. C’est l’enfant le plus bavard et le plus mignon qu’il m’est venu de voir. Même complètement déshydraté, en choc hypovolémique, il multipliait les sourires, enterrés sous ses cernes oculaires de choléra. Maintenant, c’est mon petit pot de colle, il m’appelle "Muzungu!!!" et me suit partout à l’hôpital, entre les tentes. Je caresse secrètement des fantaisies de l’adopter, mais sa mère protesterait, sans doute...


Inauguration de notre nouvelle salle d’op juste à temps pour la visite du chirurgien expat. Les murs sont émeraude, bien agencés aux draps et aux tuniques...




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Of epilepsy and fires


Apolline, whom I had mentioned a few months ago, tragically died in Lubumbashi. She did not survive the skin grafting procedure. In developing countries, burns and epilepsy come hand-in-hand: the twinkling lights of cooking fires trigger the seizures that make children fall into the flames.

J looks around ten years old although his father states that he is past fifteen. He fell into a fire during an epileptic fit two weeks ago. He suffered extensive second and third degree burns to his arms, legs and trunk, but fortunately not to his face. He was brought to Shamwana by the outreach team a few days after the event. His burns were still seeping and by the time he arrived, were producing a greenish exsudate. Thanks to those who have responded with regards to the vinegar dressings for Pseudomonas aeruginosa. In the end, a few days of oral cipro did the trick, but we are preciously keeping the vinegar for the next one.

I helped out with a dressing change of J last week. While we were taking off the dressings, he was crying in pain, calling “Kaka” (big sister in Kiluba), and begging any sorcerer to enchant him to not have to go through the procedure. Through the tears, he was still answering "Présent!" to his name when I gently called. But once the dressings were off, while we doctors were inspecting his wounds, something strange happened. All of a sudden, he became silent, grabbed my wrist and stretched stiffly. His eyes emptied and took the colour of terror; his breath shortened. Only when he started walking on all fours in circles on the bed, on his exposed burns, did I realize that he was having an atypical seizure in front of us. I had only seen the classical generalized tonic-clonic kind. J’s fit really looked like possession: panicked eyes, fixed face, erratic, animal-like behaviour. We had to hold him tightly and softly call his name. Finally, after a few minutes, he came to, as if nothing had happened. The crying started right back on the note where it was interrupted, and he continued calling for his mother and sister and answering "Présent!" to his name again. Witnessing such an odd event made me reflect on the notions of black spells and possession that are rampant in African lore. It is hard not to believe in it when one sees the absence in the eyes of an epileptic during a fit, when one has no medical understanding of the disease.


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Of Shamwana, epicentre of epidemics


We seem to be collecting field experience straight out of Manson’s Tropical Diseases textbook. Apparently, with us Canadians, all sorts of adrenaline-charged events landed in a previously sleepy Shamwana. Since September, we’ve had an influx of tuberculosis cases, the bane of cholera in Kishale, an outburst of twin pregnancies, threats of a meningitis outbreak, and now... measles has arrived. I make sick jokes that the only diseases missing are the bubonic plague or, God help us, Ebola. (No worries for those back home, I would get evacuated pronto if Ebola was to appear here. People much more capable than me would handle it.) It’s truly the full MSF experience, complete with all epidemics!

Measles spreads like bushfire. If national vaccination programs were carried out properly, it would not be an issue. Unfortunately, our remoteness does not allow the Ministry of Health to deliver the vaccines with the appropriate cold chain, so children have not been vaccinated for a long time. Measles is extremely infectious. Once there is a confirmed case, we must declare an outbreak. It is a clinical diagnosis: fever, rash (hard to distinguish on ebony skin), conjunctivitis, and coryza. Young children are usually affected, and the older they are when they catch it, the worse it is. The complications can be severe: malnutrition, blindness, severe respiratory disease, death. The children look miserable, burning with fever, sunlight hurting their wincing, swollen, purulent eyes. The measled, the miserabled. Measles spreads faster than lightning. One child can infect 17-20 others. During my four-day absence to Dubie, an outbreak of 29 cases of measles exploded in Monga, one of our villages. Isolation is key in handling a measles outbreak. We have sent a tent, medications, heaps of vitamin A, and a nurse to Monga in order to isolate them all. The numbers seem to have reached a plateau at 41. I’ve now seen a handful of Koplik’s spots, the pathognomic blue or white spot on the palate or buccal mucosa which I’d only seen in books. Overall, a measles outbreak isn’t as resource-intensive as a cholera outbreak, but it spreads more rapidly so fast action is still required. Vaccination is key to the containment of measles. However, with our limited resources, it hasn’t been possible, and the red-tape filled response from the Ministry of Health has been reticent and yet capital told us to respect it. So for now, we just have to sit back and see what happens...



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Pictures from a little week-end in Dubie, where I arrived atop a massive truck called a Unimog...


Children in Dubie on giant termite mounds




Doing the laundry under the bridge in Dubie